Provider Demographics
NPI:1083980700
Name:TEAL-SURRATT, VANDELIA (NP)
Entity Type:Individual
Prefix:
First Name:VANDELIA
Middle Name:
Last Name:TEAL-SURRATT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1469 HILLIAN EDWARDS RD
Mailing Address - Street 2:
Mailing Address - City:CHERAW
Mailing Address - State:SC
Mailing Address - Zip Code:29520-5652
Mailing Address - Country:US
Mailing Address - Phone:843-910-7587
Mailing Address - Fax:
Practice Address - Street 1:5665 NEW NORTHSIDE DR STE 320
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-5834
Practice Address - Country:US
Practice Address - Phone:404-645-7563
Practice Address - Fax:770-874-6884
Is Sole Proprietor?:No
Enumeration Date:2012-03-27
Last Update Date:2015-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC17777363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health